MEDICARE: MARISSA VIOLA SMITH MA, LPC, LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YP2500X	Professional Counselor	LPC.0014671	CO

General Provider Information

NPI Number	:	1093244485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA VIOLA SMITH MA, LPC, LAC

Provider Business Mailing Address
First Line	:	11001 W 120TH AVE STE 200
Second Line	:
City	:	BROOMFIELD
State	:	CO
Zip	:	80021-3493
Country	:	US
Telephone Number	:	720-319-7468
Fax Number	:

Provider Business Practice Location Address
First Line	:	11001 W 120TH AVE STE 200
Second Line	:
City	:	BROOMFIELD
State	:	CO
Zip	:	80021-3493
Country	:	US
Telephone Number	:	720-319-7468
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2017
Last Update Date	:	06/03/2022

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